Macular grid laser photocoagulation in uveitis

Uveitic Macular Edema: Treatment Update

The aim of this review is to summarize recent developments in the treatment of uveitic macular edema (ME). ME represent a major cause of visual loss in uveitis and adequate management is crucial for the maintenance of useful vision in patients with chronic uveitis.

Interventions for the treatment of uveitic macular edema: a systematic review and meta-analysis

Background

Uveitic macular edema is the major cause of reduced vision in eyes with uveitis.

Objectives

To assess the effectiveness of interventions in the treatment of uveitic macular edema.

Search strategy

Cochrane Central Register of Controlled Trials, Medline, and Embase. There were no language or data restrictions in the search for trials. The databases were last searched on December 1, 2011. Reference lists of included trials were searched. Archives of Ophthalmology, Ophthalmology, Retina, the British Journal of Ophthalmology, and the New England Journal of Medicine were searched for clinical trials and reviews.

Selection criteria

Participants of any age and sex with any type of uveitic macular edema were included. Early, chronic, refractory, or secondary uveitic macular edema were included. We included trials that compared any interventions of any dose and duration, including comparison with another treatment, sham treatment, or no treatment.

Data collection and analysis

Best-corrected visual acuity and central macular thickness were the primary outcome measures. Secondary outcome data including adverse effects were collected.

Conclusion

More results from randomized controlled trials with long follow-up periods are needed for interventions for uveitic macular edema to assist in determining the overall long-term benefit of different treatments. The only intervention with sufficiently robust randomized controlled trials for a meta-analysis was acetazolamide, which was shown to be ineffective in improving vision in eyes with uveitic macular edema, and is clinically now rarely used. Interventions showing promise in this disease include dexamethasone implants, immunomodulatory drugs and anti-vascular endothelial growth-factor agents. When macular edema has become refractory after multiple interventions, pars plana vitrectomy could be considered. The disease pathophysiology is uncertain and the course of disease unpredictable. As there are no clear guidelines from the literature, interventions should be tailored to the individual patient.

Recent developments in the treatment of posterior uveitis

Uveitis is an intraocular inflammation that can be caused by infection, autoimmune disease, trauma or malignancy. It is a serious cause of visual handicap and therapy is targeted at: removal of possible infectious agents, the immunological processes that lead to or sustain the inflammation and finally to prevent or treat the destructive effects of the inflammation on the delicate ocular structures. In this review the latest developments concerning the treatment of posterior uveitis are illuminated, e. g., new approaches concerning the treatment of infectious uveitis including the therapy of herpes virus (VZV, HSV and CMV), bacterial and toxoplasma infections of the eye. Several new ways to influence the immune response and inflammation are described including the use of interferons, modulation of cytokines, soft steroids, other new immunosuppressive drugs and treatment of autoimmune uveitis by oral tolerization. An overview is given to illustrate new ways to administer drugs into eyes, such as intravitreal devices. Finally new developments in the field of the treatment of the various complications of uveitis (cystoid macular edema) are described.

Intermediate Uveitis

Intermediate uveitis is an intraocular inflammation involving the anterior vitreous, peripheral retina and pars plana. It usually affects patients from 5 to 30 years old, without gender or racial preferences. The etiology is unknown but there are several associated diseases: multiple sclerosis, idiopathic optic neuritis, autoimmune corneal endotheliopathy, sarcoidosis, thyroid diseases and inflammatory bowel diseases. Symptoms are blurry vision, floaters and distortion of central vision. The syndrome is bilateral in 80% of the patients and chronic with periods of exacerbation and remission. Clinical presentation includes: mild to moderate anterior chamber inflammation, thin keratic precipitates in the inferior portion of the cornea, autoimmune endotheliopathy, vitreitis, vasculitis in the peripheral retina, intravitreal "snowballs," retinal "snowbanking," optic neuritis and cystoid macular edema. Cataract and glaucoma are frequent complications. Treatment of intermediate uveitis is based on periocular and oral corticosteroids. Cryotherapy or laser photocoagulation of the peripheral retina are options in patients with snowbanking when there is an insufficient response to periocular or systemic corticosteroids. Imunosuppression may also be used when other therapies fail, and Cyclosporin A is the first drug of choice. Pars plana vitrectomy is indicated in patients with chronic significant inflammation, non-responsive cystoid macular edema, non-clearing vitreous hemorrhage, tractional retinal detachment and epiretinal membranes. The long-term prognosis of intermediate uveitis is usually good, particularly with strict control of inflammation and with proper management of complications. Patients can often maintain a vision of 20/50 or better.

Intravitreal bevacizumab (Avastin) for the treatment of cystoid macular edema in Behçet disease

PURPOSE

To investigate the effect of bevacizumab on cystoid macular edema in Behçet disease.

METHODS

Twelve eyes of 11 patients with Behçet disease underwent optical coherence tomography, fluorescein angiography, and visual acuity measurement before and after the intravitreal injection of Avastin to evaluate its effect.

RESULTS

The visual acuity improved in 7 eyes. Foveal thickness and macular volume did not show statistically significant differences. Fluorescein angiography reduced in grading in 4 patients and was deteriorated in 2.

CONCLUSIONS

The intravitreal injection of Avastin could be effective in the improvement of the vision in patients with uveitis secondary to Behçet disease.

Intravitreal steroids in the management of macular oedema

The use of intravitreal corticosteroids in the management of macular oedema has recently gained widespread acceptance. New long-acting steroid preparations and methods of delivery have facilitated the use of these new modalities. This review describes the various types of macular oedema for which this therapeutic option is used and the results.

Outcome of intravitreal triamcinolone in uveitis

PURPOSE

To report the short-term outcome of intravitreal triamcinolone acetate (TA) in the treatment of uveitic cystoid macular edema (CME).

DESIGN

Retrospective noncomparative (nonrandomized, uncontrolled) interventional case series.

PARTICIPANTS

Sixty-five eyes of 54 patients with uveitis-related CME inadequately responsive to treatment combinations of oral corticosteroid, periocular orbital floor corticosteroid injections, and second-line immunosuppressive agents.

INTERVENTION

Intravitreal injection of 4 mg/0.1 ml of TA.

MAIN OUTCOME MEASURES

Visual acuity (VA), intraocular pressure (IOP), levels of inflammation, and immunosuppressive therapy were assessed. Other potential complications, including cataract progression, vitreous hemorrhage, endophthalmitis, and retinal detachment (RD), were looked for.

RESULTS

The mean follow-up was 8.0 months (range, 3-51), and the mean improvement of VA after intravitreal TA was 0.26 (from 0.65 to 0.39 logarithm of the minimum angle of resolution; Snellen, 6/24-6/12, approximately). This occurred at a mean of 4 weeks (range, 1-30). The improvement in VA was more significant if the duration of CME before intravitreal TA was < or =12 months (P = 0.006) and if patients were < or =60 years old (P = 0.005). Patients with the worst vision before treatment also improved the least. The most important side effect was raised IOP (mean rise, 10.3 mmHg), with 28 eyes (43.1%) experiencing an IOP rise of >10 mmHg. Patients younger than 40 years were more likely to experience this IOP rise than those older than 40. Thirty-three eyes (51%) were treated with antiglaucoma medications, with a mean duration of treatment of 17.4+/-13.3 weeks, and no patient required trabeculectomy or lost vision. The dosage of oral corticosteroids and/or second-line immunosuppressive medication was reduced or stopped altogether in 18 of 33 eyes (54.5%) during the study period. There were no cases of injection-related vitreous hemorrhage, endophthalmitis, or RD.

CONCLUSIONS

In patients with uveitic CME, intravitreal TA can effectively reduce CME and improve VA and, in some eyes, allows the cessation and/or reduction of immunosuppressive therapy. The period of effectivity varies in different patients and, in some eyes, is limited. Treatment was associated in 43.1% with a rise in IOP, which was transient and treatable medically.

Evaluation of the effect of acetazolamide on cystoid macular oedema in patients with Behcet's disease

AIM

To study the effect of acetazolamide on cystoid macular oedema (CMO) in patients with Behcet's disease.

PATIENTS AND METHODS

A total of 67 eyes of 35 Behcet's patients with chronic, but well-controlled uveitis, and CMO were randomised into a double-masked, crossover trial comparing the effect of acetazolamide vs placebo. The patients received an initial 4-week course of either 250 mg acetazolamide twice daily (b.i.d.) or placebo, followed by a 4-week washout period. They then received a 4-week course of the reverse study medication. An improvement in visual acuity and fundus fluorescein angiographic findings was assessed.

RESULTS

In total, 29 patients (55 eyes) completed the trial and were available for analysis. Of the 29, 16 men and 13 were women. The age range was 13-50 years (mean 33.6 years). Patients on acetazolamide showed a slightly better improvement of angiographic signs (at least by one grade improvement) over that of placebo (12 vs five eyes). They also had less deterioration of angiographic signs over that of placebo (three vs seven eyes). However, these findings were not statistically significant (P=0.99). Acetazolamide had no statistically significant effect (P=0.53) on the improvement of visual acuity of patients over that of placebo (13 vs eight eyes), nor on the deterioration of visual acuity (three vs 11 eyes).

CONCLUSION

Despite seemingly favourable results, the 4-week course of acetazolamide (250 mg b.i.d.) has no statistically significant effect on the improvement of the visual acuity and the fluorescein angiographic findings in Behcet's patients with CMO.

Safety and efficacy of intravitreal triamcinolone for cystoid macular oedema in uveitis

PURPOSE

To report the safety and efficacy of intravitreal triamcinolone in the treatment of inflammatory cystoid macular oedema (CMO) in six patients who were resistant to other forms of therapy.

METHODS

An open-label unmasked prospective nonrandomized pilot study of six patients with idiopathic uveitis and visually significant macular oedema, resistant to periocular and/or systemic corticosteroid treatment, was carried out. Baseline examination and investigations were performed, including fundus fluorescein angiography, and the patients were given a single intravitreal injection of triamcinolone (4 mg/0.1 mL). The primary outcome measure was angiographic resolution of CMO. Patients were reviewed at intervals of 2-4 weeks for 12 months.

RESULTS

A single intravitreal injection of triamcinolone induced clinical and angiographic resolution of inflammatory macular oedema in all patients for varying periods of time up to 6 months. Five patients experienced increased intraocular pressure to 30 mmHg or greater which required treatment. Two patients developed posterior subcapsular cataract.

CONCLUSION

One injection of intravitreal triamcinolone was an effective short-term treatment for resistant CMO in uveitis. As with steroids given by other routes, raised intraocular pressure and cataract may occur. As it was so effective in these eyes with resistant CMO, a larger study is warranted to evaluate this form of therapy.

Cystoid macular oedema in uveitis: an unsolved problem

Most papers on the subject of CMO associated with uveitis are retrospective, combine patients with different disease aetiologies, at different stages of evolution, and often describe patients who were previous treatment failures with other therapies besides the one under consideration. There are almost no prospective randomised double-masked controlled studies. This is perhaps in part due to the relative sparsity of uveitis patients seen by many uveitis centres. At the moment, treatment is largely empirical, based in large part on the studies, and others, quoted above. The need to regularly repeat courses of therapy, loss of efficacy of certain form of therapy after repeated use, and cumulative side-effects, all need to be taken into consideration when interpreting results and deciding upon the best approach to be adopted. The risks to the patient's well-being increase with the addition of systemic medication, and long-term steroid use can cause hypertension, induce or exacerbate diabetes, cause premature osteoporosis, cushingoid features, peptic ulceration and aseptic necrosis of the femoral head. Immunosuppressive drugs can be nephrotoxic, hepatotoxic, cause hypertension, gastric disturbances and excessive hair growth. The assessment of macular changes, both structurally and functionally, is the key aspect in understanding visual loss in CMO and also in predicting potential visualrecovery. The combined use of the various tools mentioned here, such as SLO, OCT and electrodiagnostic tests, may give us some of the necessary answers in this process. However, all these tests will need to be validated. A prospective analysis of CMO in cases of uveitis, especially if coupled with therapeutic intervention, will give us the opportunity to achieve this objective.

Grid laser photocoagulation for macular oedema in uveitis or the Irvine-Gass syndrome

AIMS

To determine the effect of modified macular grid photocoagulation in patients with refractory macular oedema due to uveitis or cataract extraction.

METHODS

In this study 20 patients with macular oedema underwent modified macular grid laser photocoagulation and were followed by means of standardised examinations (day 0, months 2, 6, and 12) consisting of best corrected visual acuity and fluorescein angiography.

RESULTS

The mean visual acuity increased from 0.16 before to 0.3 after laser treatment (p = 0.013), and fluorescein leakage was significantly reduced (p = 0.005). Visual prognosis was influenced by duration of the uveitis, not by sex or age.

CONCLUSION

Modified macular grid laser photocoagulation had a beneficial effect on macular oedema caused by uveitis or the Irvine-Gass syndrome. A prospective, randomised study is needed to determine the exact place of modified macular grid photocoagulation in the treatment of patients with inflammatory or postsurgical macular oedema.

New therapeutic options in uveitis

Most patients with sight-threatening posterior uveitis eventually end up on systemic medication to control their disease. Although the more aggressive approach to the use of these drugs does offer the patient a better chance of significant visual improvement at least in the short term, this is often associated with severe systemic side-effects in both the young and older patient. Cyclosporin has become a very useful second-line agent as a steroid sparer in those patients who can tolerate it. However, it is not suitable for or effective in everyone and the other currently available drugs are often of limited effectivity or associated with major systemic sequelae. This paper summarises the therapeutic approaches currently being examined to define whether they have a role in the better management of these patients in the future. Particularly exciting is the potential for sustained intraocular drug delivery so that adequate drug levels are achieved inside the eye without the necessity for systemic administration.